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  • 1
    Electronic Resource
    Electronic Resource
    Kontinuierliche intravasale Blutgasanalyse (1994)
    Springer
    Der Anaesthesist 43 (1994), S. 642-647 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Blutgasanalyse, fiberoptisch – Sauerstoffpartialdruck – Kohlendioxidpartialdruck – Wasserstoffionenkonzentration ; Key words: Blood gas analysis – Fiber-optics – Partial pressure – Oxygen – Carbon dioxide – Hydrogen-ion concentration
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Continuous monitoring of blood gases and pH could add substantially to patient safety. During the last decade, efforts have been made to develop continuous optochemical blood gas sensors. The initial evaluation of such fibreoptic-based systems showed major patient-interface problems [11]. We evaluated a new intra-arterial blood gas monitoring system (PB3300, Puritan-Bennett, Carlsbad CA) under routine clinical conditions. Methods. After institutional review board approval and with written informed consent, 38 sensors were tested in 25 patients with acute respiratory failure (e.g., the acute respiratory distress syndrome, complications after lung transplantation). Two conventional bench-top blood gas analysers (ABL 520 and ABL 300, Radiometer, Copenhagen) served as criterion standards. The mean differences (bias) and standard deviations (SD) of the differences (precision) were calculated according to the method of Bland and Altman [2]. In addition, linear regression analysis and correlation coefficients were calculated. The quality of blood pressure tracings was assessed using a grading system. Results. The median sensor lifetime was 81.3 h; 869 blood samples (median 14 per sensor) were analysed for the comparison of continuous and conventional blood gas analysis. The ranges for measured parameters were: pH: 6.92 to 7.55; PCO2: 20 to 83 torr; PO2: 31 to 518 torr. The mean differences (SD) were: pH: −0.03 (0.03) or −0.4 (0.4)%; PCO2: −2.6 (4.1) torr or −6.9 (10.9)%; PO2: −3.4 (10.5) torr or −2.9 (7.0)%. The results of linear regression analysis and the correlation coefficients are depicted in Table 2. The mean grade of blood pressure tracings was satisfactory for the clinical setting. Conclusions. The continuous blood gas monitor is sufficiently accurate and precise for clinical use. Bias and precision are better than those known from former studies evaluating fibreoptic blood gas monitors under experimental conditions [7]. Cost-effectiveness was not an issue of this study.
    Notes: Zusammenfassung. Ein neuer kontinuierlicher intravasaler Blutgasmonitor auf optochemischer Basis (PB3300, Puritan-Bennett) wurde im klinischen Routineeinsatz auf der Intensivstation bei Patienten mit respiratorischer Insuffizienz getestet. 38 Sensoren wurden bei 25 Patienten implantiert. Als Standard dienten Blutproben, gemessen in zwei konventionellen Blutgasanalysatoren (ABL 520 und ABL 300, beide Radiometer). Die mittleren Differenzen (Standardabweichung der Differenzen) als Maß für die Übereinstimmung beider Methoden betrugen für den pH −0,03 (0,03) oder −0,4% (0,4), für den PCO2−2,6 mm Hg (4,1) oder −6,9% (10,9) und für den PO2−3,4 mm Hg (10,5) oder −2,9% (7,0). Für den klinisch relevanten Bereich (PO2〈150 mm Hg) betrug die mittlere Differenz −2,0 mm Hg (5,8) oder −2,6% (6,8). Die Korrelationskoeffizienten zwischen konventioneller und kontinuierlicher Blutgasanalyse betrugen zwischen 0,90 (pH) und 0,99 (PO2). Die Steigerungen der Regressionsgeraden lagen zwischen 0,97 und 1,09. Die kontinuierliche Blutgasmessung auf optochemischer Basis scheint das Stadium der klinischen Anwendbarkeit erreicht zu haben.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050104
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  • 2
    Electronic Resource
    Electronic Resource
    Die kontinuierliche Messung des Herzzeitvolumens mit der Pulskonturanalyse (1995)
    Springer
    Der Anaesthesist 44 (1995), S. 493-500 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Kontinuierliche Herzzeitvolumenmessung ; Pulskonturmethode ; kritisch Kranke ; hämodynamisches Monitoring ; Key words Continuous cardiac output ; Haemodynamic monitoring ; Intensive care patients ; Pulse contour analysis ; Vasoactive agents
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Pulse contour cardiac output (PCCO) is an easily applicable method for continuous measurement of cardiac output in critically ill patients. Calculation of stroke volume is possible by analysing the area under the systolic part of the arterial pulse pressure waveform together with an individual calibration factor (Zao) to account for the individually variable vascular impedance. Since vascular impedance is potentially affected by altered vascular tone, it was the aim of the present study to examine the validity of PCCO in ICU patients receiving various dosages of a variety of vasoactive drugs. Patients and methods. Continuous cardiac output was measured in 20 ICU patients for a total of 110 h using the pulse contour method. The precision of PCCO was determined in comparison with its calibration reference, the thermodilution method (TDCO): (1) during administration of vasoactive drugs at a constant rate and (2) during conditions with altered vascular tone and haemodynamics elicited by changes in vasoactive drug dosage. For this purpose, the patients received varying dosages of vasoactive drugs (dopamine, dobutamine, epinephrine, norepinephrine, nitroglycerin, prostacycline and urapidil). Results. A total of 165 data sets was obtained, each consisting of the average of four capnometrically triggered TDCO measurements and the corresponding PCCO values. The relative difference between methods (±2 SD) was ±23.9% (SD 0.85 l ·min−1; r=0.93) if a single calibration at the beginning of measurement series was performed (Fig. 2). The bias of the mean cardiac output values of both methods was −0.09 l·min−1. The precision of PCCO improved to ±15.7% by additional calibrations (SD 0.56 ·min−1; r=0.96; bias 0.003 l·min−1). Data of two patients showed that recalibration may be necessary after extreme haemodynamic changes due to septic shock or cooling. Alteration of vascular tone by clinically used dosage of vasoactive drugs, however, had no destabilizing effect on the pulse contour method. Conclusions. It could be demonstrated that PCCO provides a valuable method for continuous cardiac output measurement in the intensive care setting with a precision comparable to that of thermodilution.
    Notes: Zusammenfassung Die Pulskonturanalyse ist ein einfach anzuwendendes Verfahren zur kontinuierlichen Bestimmung des Herzzeitvolumens (PCCO) bei kritisch kranken Patienten. Die Berechnung des Schlagvolumens erfolgt über die Analyse der arteriellen Pulsdruckkurve zusammen mit einem für jeden Patienten mittels Referenzverfahren individuell zu bestimmenden Kalibrationsfaktor. PCCO wurde an 20 Intensivpatienten über eine Gesamtzeit von 110 h gemessen und mit Thermodilutionswerten (TDCO) verglichen. Die relative Abweichung (±2 SD) von PCCO gegenüber TDCO wurde ermittelt: (1) unter hämodynamisch stabilen Bedingungen, und (2) unter Bedingungen von verändertem Vasotonus und Hämodynamik bei Dosisänderungen vasoaktiver Substanzen. Insgesamt wurden an 165 Meßzeitpunkten TDCO-Messungen durchgeführt und die korrespondierenden PCCO-Werte registriert. Die relative Abweichung von PCCO gegenüber TDCO betrug ±23,9% (SD=0,85 l·min −1 ), wenn die PCCO-Methode einmalig bei jedem Patienten vor Beginn der Meßserien kalibriert wurde. Die Differenz der Mittelwerte der Herzzeitvolumina (CO) beider Methoden (Bias) war dabei −0,09 l·min −1 . Durch zusätzliche Kalibrationen konnte die relative Abweichung (±2 SD) auf ±15,7% verbessert werden (SD= 0,56 l·min −1 ; Bias 0,003 l·min −1 ). Änderungen in der Dosierung vasoaktiver Substanzen in klinisch üblichen Größenordnungen hatten keinen Einfluß auf die Meßgenauigkeit von PCCO. Es konnte gezeigt werden, daß die Pulskonturanalyse ein leicht anzuwendendes und klinisch ausreichend genaues Verfahren zur kontinuierlichen Messung des CO darstellt.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050182
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  • 3
    Electronic Resource
    Electronic Resource
    Die Wirkung von Aprotinin Blutverlust und Gerinnungsparameter bei orthotoper Lebertransplantation: Eine klinisch-experimentelle, prospektive und randomisierte Doppelblindstudie (1997)
    Springer
    Der Anaesthesist 46 (1997), S. 294-302 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Lebertransplantation ; Aprotinin ; Transfusionsbedarf ; Gerinnungsparameter ; Key words Liver transplantation ; Aprotinin ; Transfusion requirements ; Coagulation parameters
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract The effect of aprotinin (2000000 IU as a bolus +500000 JU/h until the end of the operation) on transfusion requirements and coagulation parameters in orthotopic liver transplantation (study group: n=9; placebo group: n=9) was investigated in a randomised, double-blind study. Coagulation parameters were monitored intraoperatively using a mobile laboratory. In contrast to the published results, no effect on transfusion requirements could be demonstrated. However, aprotinin showed a positive effect on some coagulation parameters in the reperfusion phase. The mechanism appeared to be inhibition of the contact activation of the intrinsic system with less thrombin generation in the study group.
    Notes: Zusammenfassung In einer randomisierten Doppelblindstudie wurde der Effekt von Aprotinin (2000000 KIE als Bolus+500000 KIE/h bis zum Ende der Operation, Verumgruppe n=9; Plazebogruppe n=9) auf Gerinnungsparameter und Transfusionsbedarf bei orthotoper Lebertransplantation untersucht. Alle Patienten wurden mit Hilfe eines fahrbaren Gerinnungslabors intraoperativ optimal überwacht. Im Gegensatz zu anderen Arbeitsgruppen fand sich unter diesen Bedingungen für den Transfusionsbedarf kein signifikanter Unterschied zwischen Verum- und Plazebogruppe. Dagegen beobachteten wir einen günstigen Effekt des Proteinaseninhibitors auf verschiedene Gerinnungsparameter, besonders in der Reperfusionsphase. Offensichtlich wird die Kontaktaktivierung des intrinsischen Gerinnungssystems, die durch geschädigte Gefäße des transplantierten Organs eingeleitet wird, durch Aprotinin gehemmt.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050404
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  • 4
    Electronic Resource
    Electronic Resource
    Generalisierte Gasbrandinfektion mit Rhabdomyolyse nach Cholezystektomie (1997)
    Springer
    Der Anaesthesist 46 (1997), S. 207-210 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Cholezystektomie ; Clostridium perfringens ; Gasbrand ; Rhabdomyolyse ; Sepsis ; Key words Cholecystectomy ; Gas gangrene ; Clostridium perfringens ; Rhabdomyolysis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract We report a rare case of spontaneously developing generalised gas gangrene with massive rhabdomyolysis after a cholecystectomy and drainage of a hepatic abscess. On preoperative physical examination the patient appeared severely ill and was icteric and oliguric. Laboratory evaluation showed signs of systemic inflammation, elevated lactate levels, evidence of disseminated intravascular coagulation (DIC), and increased levels of serum creatine kinase (CK) activity. Abdominal ultrasound and endoscopic retrograde cholangiography showed a gallbladder perforation and a hepatic abscess. Cholecystectomy and drainage of the abscess was performed immediately and without technical problems. After postoperative admission to the intensive care unit, the patient showed evidence of generalised myonecrosis with subcutaneous gas formation and acute renal failure. Initially, there were few other signs of systemic toxicity; the patient was not hypotensive and the pulmonary gas exchange was normal. Within hours diffuse swelling of his right leg developed with cutaneous gangrene and a compartment syndrome. After fasciectomy and extensive surgical debridement, uncontrollable bleeding due to DIC developed from the fasciectomy site, which finally required exarticulation of the leg at the hip joint. At this point, multiple organ failure including severe adult respiratory distress syndrome was present. Two days after cholecystectomy, the patient died from hypoxic cardiocirculatory failure. Clostridium perfringens was repeatedly isolated from the wounds. Besides gas gangrene, the differential diagnosis of such infections includes localised clostridial cellulitis, nonclostridial anaerobic cellulitis caused by mixed aerobes and anaerobes, and type I or type II necrotising fasciitis. Patients with systemic necrotising infections should be treated with broad-spectrum antimicrobial regimens (penicillin G, 3rd generation cephalosporins, clindamycin, and aminoglycosides). An otherwise unexplained elevation of serum CK activity in the presence of acute cholecystitis may suggest haematologic spread of an aggressive myolytic agent and the beginning of myonecrosis. This should prompt immediate surgical exploration after establishing broad-spectrum antibiotic coverage. The role of hyperbaric oxygen treatment in this situation remains to be established. If hyperbaric oxygen is to be employed, it should neither delay surgical exploration nor jeopardise the patient with the hazards of an interhospital transport.
    Notes: Zusammenfassung Kasuistik: Wir berichten über den seltenen Fall einer spontan aufgetretenen Gasbrandinfektion mit generalisierter Rhabdomyolyse bei einem 64jährigen Patienten nach Cholezystektomie wegen einer perforierten Cholezystitis. Präoperativ war bei dem Patienten neben laborchemischen Entzündungszeichen besonders eine isolierte Erhöhung der Kreatinkinasekonzentration im Serum auffällig. Er entwickelte nach der Cholezystektomie eine generalisierte nekrotisierende Weichteilinfektion mit Hautemphysem und Rhabdomyolyse. Innerhalb von Stunden kam es zu einem Kompartmentsyndrom im Bereich des rechten Ober- und Unterschenkels. Trotz einer Faszienspaltung und einer späteren Exartikulation im Hüftgelenk entwickelte der Patient eine generalisierte Gasbrandinfektion mit disseminierter intravasaler Gerinnung. Der Patient verstarb zwei Tage nach Krankenhausaufnahme. Mikrobiologisch fand sich in den Wundabstrichen Clostridium perfringens. Differentialdiagnostisch ist bei derartigen fulminant verlaufenden Krankheitsbildern vor allem an eine Infektion durch Clostridien oder andere Anaerobier sowie an eine nekrotisierende Fasziitis Typ I oder Typ II zu denken. Therapie: Die gezielte und sofort zu beginnende Antibiotikatherapie sollte neben Penicillin G auch ein Cephalosporin der 3. Generation, Clindamycin und ein Aminoglykosid umfassen. Bei einer anderen Ursachen nicht zuzuordnenden Erhöhung der Kreatinkinase bei Cholezystitis muß an das Vorliegen einer disseminierten Infektion mit Myonekrose gedacht werden. Der Einsatz der hyperbaren Oxygenation in einer derartigen Situation kann erwogen werden, diese Maßnahme darf aber weder ein entschlossenes chirurgisches Vorgehen verzögern noch den Patienten zusätzlich gefährden.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050393
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  • 5
    Electronic Resource
    Electronic Resource
    Veno-venöse extrakorporale Membranoxygenierung (ECMO) mit heparinbeschichtetem Bypass-System Eine effektive Erweiterung bei der Behandlung des akuten Lungenversagens (ARDS) (1996)
    Springer
    Der Anaesthesist 45 (1996), S. 437-448 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Akutes Lungenversagen ; Maschinelle Beatmung ; Extrakorporale Membranoxygenierung ; Barotrauma ; Volutrauma ; Key words Respiratory distress syndrome ; adult ; Ventilation ; mechanical ; Extracorporeal membrane oxygenation ; Barotrauma ; Volutrauma
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Mortality of severe acute respiratory distress syndrome (ARDS) in Germany is about 60%. Respiratory therapy can make the lung injury worse by high positive airway pressures, high tidal volumes and high inspiratory oxygen concentrations. Extracorporeal membrane oxygenation (ECMO) was employed to reduce aggressive mechanical ventilation, but it has not been proved to be superior to conventional ventilation. However, encouraged by recently developed improvements in the technique and concept of ECMO, we introduced this therapy into our program for the treatment of ARDS. Patients and methods. All patients with severe ARDS (lung injury score 〉2.5) admitted to our multidisciplinary intensive care unit from March 1992 to March 1995 were evaluated prospectively. After admission, the patients first underwent a conventional therapeutic approach, including pressure-controlled inverse-ratio ventilation, permissive hypercapnia, changes in body position (in particular, the prone position), negative fluid balance, antibiotics, and low-dose hydrocortisone infusion. ECMO via a covalently heparin-coated, venovenous bypass-system with a vortex pump and two membrane lungs was performed if ARDS did not improve after 24–96 h of conventional therapy and if two of three of the slow-entry criteria for ECMO were fulfilled: (1) PaO2/FiO2 〈150 mmHg at PEEP 〉5 mbar; (2) semistatic compliance 〈30 ml/mbar; (3) right-left shunt 〉30%. Only in cases of life-threatening hypoxemia (PaO2 〈50 mmHg at FiO2 1.0 and PEEP 〉5 mbar for 〉2 h (fast-entry criteria) was ECMO instituted immediately. Results. Sixty patients fulfilled the entry criteria for our study. Thirty-nine patients were treated with a conventional protocol, 37 after improvement of ARDS and 2 who had not improved but in whom there were contraindications to the use of ECMO. ECMO was performed in 10 patients who had not improved, but who fulfilled the slow-entry criteria and in 11 primarily hypoxemic patients who fulfilled the fast-entry criteria. The survival rate was 30/39 (77%) for the conventional therapy group, 6/10 (60%) for the slow-entry group, and 11/11 (100%) for the fast-entry group. The onset of ECMO allowed a significant decrease in peak and mean airway pressures, tidal volume, ventilatory rate, minute volume and inspiratory oxygen concentration. Sufficient gas exchange was provided, and pulmonary artery pressures significantly decreased on bypass. The most frequent complications on bypass were pneumothorax (15/21 patients) and bleeding (7/21 patients). Conclusion. In comparison with the historical results at our own institution, the present study demonstrates an improvement in the survival rate from 56% to 78% since ECMO has become available. We conclude that venovenous ECMO with a heparin-bonded bypass circuit is an effective additional option for the treatment of patients with severe ARDS.
    Notes: Zusammenfassung Die Letalität des ARDS ist nach wie vor hoch. Um den Stellenwert der ECMO als zusätzliche Behandlungsoption zur konventionellen Beatmungstherapie zu untersuchen, wurden 60 Patienten mit schwerem ARDS prospektiv evaluiert. 39 Patienten wurden konventionell behandelt, weil sich ihr pulmonaler Gasaustausch besserte (n=37) oder Kontraindikationen gegen ECMO bestanden (n=2). Zehn konventionell nicht besserbare Patienten wurden nach 24 bis 96 h an ein heparinbeschichtetes, veno-venöses Bypass-System mit mikroporösen Membranlungen angeschlossen (slow entry-Gruppe). Sofort mit ECMO begonnen wurde bei 11 Patienten, die eine lebensbedrohliche Hypoxämie aufwiesen (fast entry-Gruppe). In der konventionellen Behandlungsgruppe überlebten 77%, in der slow entry-Gruppe 60% und in der fast entry-Gruppe 100% der Patienten. Nach ECMO-Beginn konnten Atemwegsdrücke, Beatmungsvolumina und inspiratorische Sauerstoffkonzentration signifikant reduziert werden. Unter ECMO wurden bei allen Patienten tolerable Blutgaswerte und ein Abfall der pulmonalarteriellen Drücke gemessen. Häufigste Komplikationen am Bypass waren Pneumothoraces und Blutungen. Im Vergleich zu früheren Jahren ergab sich im eigenen Krankengut seit Einführung der ECMO eine Steigerung der Überlebensrate des ARDS von 56% auf derzeit 78%. Die Ergebnisse zeigen, daß die veno-venöse ECMO mit heparinbeschichtetem Bypass-System eine effektive Erweiterung bei der Behandlung des schweren ARDS ist.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050278
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  • 6
    Electronic Resource
    Electronic Resource
    Gesundheitsbezogene Lebensqualität Langzeitüberlebende, erwachsene Patienten mit ARDS nach extrakorporaler Membranoxygenation (ECMO) (1998)
    Springer
    Der Anaesthesist 47 (1998), S. 24-29 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Akutes Lungenversagen ; Extrakorporale Membranoxygenierung ; Gesundheitsbezogene Lebensqualität ; SF-36 ; Key words Respiratory distress syndrome ; adult ; Extracorporeal membrane oygenation ; Health-related quality of life ; SF-36 ; Intensive care treatment
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Treatment of severe acute respiratory distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO) can be life-saving but requires maximal use of intensive care resources over prolonged periods of time, resulting in high costs. Little is known about the health-related quality of life (HRQL) in long-term survivors. This case-controlled retrospective study was designed to assess the health-related quality of life in long-term survivors of ARDS and ECMO-therapy. Methods: 14 long-term survivors of ARDS (APACHE II score=24, Lung Injury Score=3.25, median values) treated using ECMO between 1992 and 1995 (median time interval between data collection and discharge from the ICU 16 months) and 14 ARDS-patients conventionally treated during the same period (group I) were identified and completed the SF-36 Health Status Questionnaire (Medical Outcome Trust, Boston, USA). 14 healthy subjects (group II) were drawn at random from a large data base generated to provide normal values for the SF-36 in a German population. All three groups were comparable with respect to sex and age. Results: Long-term survivors of ECMO-therapy reported significant reductions in physical functioning when compared with patients treated by mechanical ventilation alone (group I, –12.5%, p〈0.05) and with healthy controls (group II, –50%, p〈0.05) and showed a higher incidence of chronic physical pain (+5% and +24%, respectively, p〈0.05). There were no differences with regard to the mental health dimensions of the SF-36 (e.g. vitality, mental health index or social functioning) between ECMO-patients and all controls. Nine patients (64.3%) from the ECMO group versus all patients treated conventionally (group I) had full-time employment (p=0.46, Chi2 test). Conclusions: The majority of long-term survivors of ECMO-treatment show good physical and social functioning, including a high rate of employment. The more aggressive approach of ECMO-therapy and a possibly more severe underlying disease process may explain impairments in health-related quality of life outcomes after ECMO-treatment. Despite these limitations, long-term survivors of ECMO-therapy are able to reach a highly satisfactory health-related quality of life.
    Notes: Zusammenfassung Einführung und Methodik: Die extrakorporale Membranoxigenation (ECMO) zur Behandlung des schweren ARDS beim Erwachsenen ist eine aufwendige und teure Methode und in Einzelfällen lebensrettend. Es existieren jedoch keine Daten zur gesundheitsbezogenen Lebensqualität (HRQL) von langzeitüberlebenden Patienten nach ECMO-Behandlung. Wir untersuchten daher 14 Patienten, die zwischen 1992 und 1995 mittels extrakorporaler Membranoxygenation behandelt wurden bezüglich der erreichten HRQL. 14 im gleichen Zeitraum konventionell therapierte ARDS Patienten (Gruppe I) und 14 gesunde Normalpersonen (Gruppe II) dienten als Kontrollen. HRQL wurde mit einem standardisierten und validierten Fragebogen (SF-36) erfaßt. Ergebnisse: ECMO-Patienten zeigten im Vergleich zu beiden Kontrollen eine schlechtere körperliche Funktionsfähigkeit um 12,5% (Gruppe I) bzw. 50% (Gruppe II) (p〈0,05) und eine höhere Inzidenz körperlicher Schmerzen (+5% bzw. +24%, p〈0,05). Demgegenüber war die psychische Gesundheit, die Vitalität und die soziale Funktionsfähigkeit der ECMO-Patienten im Vergleich zu den gesunden Kontrollen nur gering eingeschränkt (p〉0,05). Schlußfolgerung: Patienten nach ECMO-Behandlung des ARDS erreichen eine insgesamt zufriedenstellende HRQL.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050518
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  • 7
    Electronic Resource
    Electronic Resource
    ARDS und Wegener-Granulomatose (1997)
    Springer
    Der Anaesthesist 46 (1997), S. 969-973 
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    ISSN: 1432-055X
    Keywords: Schlüsselwörter Wegener-Granulomatose ; Glomerulonephritis ; ARDS ; Extrakorporale Membranoxygenation ; ECMO ; Key words Wegener’s granulomatosis ; Glomerulonephritis ; Respiratory distress syndrom ; Adult ; Extracorporeal membrane oxygenation ; ECMO
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Wegener’s granulomatosis is a distinct clinicopathologic entity characterized by granulomatous vasculitis of the upper and lower respiratory tract and glomerulonephritis. This disease can present as a clinical picture which resembles sepsis and adult respiratory distress syndrome (ARDS). Wegener’s disease requires immunosuppression which can have detrimental consequences when used in sepsis. The following case report illustrates the diagnostic difficulties encountered by intensiv care physicians treating severe pulmonary failure and multiple organ dysfunction in Wegener’s granulomatosis appearing as ARDS with sepsis. Case report: A 19-year-old female patient had developed acute respiratory and renal failure after a prolonged period (many months) of antibiotic resistant otitis, sinusitis and mastoiditis. The patient had required intubation at another hospital and there was a history of tension pneumothorax and cardiopulmonary resuscitation during mechanical ventilation. Emergency extracorporeal membrane oxygenation (ECMO) for acute hypercapnic and hypoxic respiratory failure was instituted and the patient was transported to our institution while on ECMO. The patient was treated empirically for suspected pulmonary and systemic infection and received hydrocortisone (0,18 mg/kg/h) as part of a protocol-driven treatment of septic shock in addition to antibiotic and antimycotic regime. The use of ECMO was required for 10 and mechanical ventilation for another 50 days after admission. After successfull extubation, central nervous system dysfunction became evident with a somnolent and generally unresponsive patient. When the hydrocortisone dose was gradually tapered, the clinical status of the patient further deteriorated, pulmonary gas exchange worsened and she developed renal failure with proteinura and hematuria. A renal biopsy was performed demonstrating vasculitis and focal segmental glomerulonephritis, a systemic granulomatous vasculitis was suspected; the serum was tested for anti-proteinase 3 antibodies (PR3-ANCA) and turned out to be positive (17.5 U/ml; normal range 〈7 U/ml). The morphologic findings from renal biopsy, the positive test for antiproteinase 3 antibodies and the pulmonary-renal involvement with evidence of multisystem disease established the diagnosis of Wegener’s granulomatosis. Immunosuppressive therapy with cyclophosphamide and prednisolon was instituted resulting in rapid improvement with recovery of pulmonary, renal and central nervous system function within two weeks. The use of ECMO in this patient served as a life – saving immediate measure usefull to ”buy time” until a definite diagnosis could be established. ARDS represents an uniform pulmonary reaction to a large number of different noxious stimuli and disease entities. This case demonstrates that intensiv care physicians caring for critically ill patients with ARDS should include even rare causes of pulmonary injury into their differential diagnosis.
    Notes: Zusammenfassung Wir berichten über eine 19jährige Patientin, bei der unter dem typischen Bild eines schweren ARDS mit Multiorganversagen für insgesamt 10 Tage der Einsatz einer extrakorporalen Lungenersatztherapie (ECMO) erforderlich war. Therapieverlauf: Unter einer kalkulierten antibiotischen und antimykotischen Therapie sowie einer Behandlung mit Hydrocortison als adjuvanter Therapie bei septischem Schock besserte sich erst nach wochenlangem und kompliziertem klinischen Verlauf die Lungenfunktion soweit, daß eine Extubation möglich war. Die Patientin zeigte jedoch unverändert eine Mehrorgandysfunktion von Niere, Lunge und ZNS. In den folgenden Wochen nach Beendigung der Hydrocortisontherapie verschlechterten sich Nierenfunktion, pulmonaler Gasaustausch und Vigilanz wieder. Diagnostik: Der histologische Befund der Nierenbiopsie mit Arteriitis und Glomerulonephritis bei beidseitiger Vergrößerung der Nieren im CT und der Nachweis von Proteinase 3-ANCA im Serum ermöglichten letztlich bei Würdigung des gesamten klinischen Bildes und seiner genauen Vorgeschichte eine Diagnose: Wegener-Granulomatose. Durch immunsuppressive Therapie kam es innerhalb kurzer Zeit zu einer Remission mit vollständiger Erholung insbesondere der ZNS-Funktion. Schlußfolgerung: Dieser Fallbericht zeigt, daß im Einzelfall auch seltene Krankheitsbilder mit pulmonaler Beteiligung wie die Wegener-Granulomatose in die Differentialdiagnose des ARDS einbezogen werden müssen.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050494
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  • 8
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    Electronic Resource
    Retrospektive Analyse von transpulmonal und pulmonalarteriell gemessenem Herzzeitvolumen bei ARDS-Patienten (1998)
    Springer
    Der Anaesthesist 47 (1998), S. 912-917 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Herzzeitvolumen ; Thermodilution ; Pulmonalarterienkatheter ; Herzkatheter ; Key words Cardiac output ; Thermodilution ; Catheterization ; Swan-Ganz ; Heart catheterization ; Technology ; medial
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Objectives: To investigate the agreement (and its potential dependency on extravascular lung water) between transpulmonary (TPID) and standard pulmonary artery (PAID) thermodilution cardiac output measurements. Methods: One hundred and sixty simultaneous cardiac output measurements using transpulmonary and pulmonary artery thermodilution techniques were retrospectively compared in 18 patients with acute respiratory distress syndrome. In addition, extravascular lung water was determined using a double indicator technique (temperature and indocyanine green). Results: Mean (±SD) difference (’’bias’’) was 0.03 L/min (±1.04 L/min), linear regression analysis resulted in TPID=0.87 PAID+1.16 (r=0.91). Mean extra vascular lung water was 1625 mL (minimum–maximum: 403–3266 mL) and therefore markedly elevated as could have been expected in patients with ARDS. Bias (PAID-TPID) was not dependent on extravascular lung water. Conclusions: Transpulmonary and pulmonary artery thermodilution methods can be used interchangeably. The results demonstrate for the first time in humans that transpulmonary thermodilution provides valid cardiac output values in patients with markedly increased fluid content of the lungs.
    Notes: Zusammenfassung Fragestellung: Die transpulmonale Indikatordilutionstechnik (TPID) erlaubt die Bestimmung des Herzzeitvolumens ohne Pulmonalarterienkatheter. Wir untersuchten die Übereinstimmung der TPID mit der etablierten pulmonalarteriellen Thermodilutionsmessung (PAID). Methodik: Bei 18 Patienten mit akuter respiratorischer Insuffizienz wurden simultan pulmonalarterielle und transpulmonale Herzzeitvolumenmessungen durchgeführt (160 Meßwertpaare). Außerdem wurde mittels Doppelindikatortechnik (Kälte und Indozyaningrün) das extravaskuläre Lungenwasser (EVLW) bestimmt. Ergebnisse: Die mittlere Differenz (±Standardabweichung) zwischen TPID und PAID lag bei 0,03 l/min (±1,04 l/min), die Regressionsanalyse ergab TPID=0,87 PAID+1,16 (r=0,91). Das EVLW war im Mittel mit 1625 ml (Min–Max: 403–3266 ml) in unserem Patientenkollektiv entsprechend der Grundkrankheit deutlich erhöht. Die mittlere Differenz der beiden gemessenen Herzzeitvolumina (PAID-TPID) zeigte keine Abhängigkeit vom EVLW des Patienten. Schlußfolgerungen: Die gute Übereinstimmung der TPID mit der etablierten pulmonalarteriellen Thermodilutionstechnik über einen großen Herzzeitvolumenbereich deutet darauf hin, daß ein alternativer Einsatz beider Methoden möglich erscheint. Darüber hinaus konnte erstmals an Patienten gezeigt werden, daß die TPID unabhängig vom EVLW des Patienten eine valide Herzzeitvolumenmessung ermöglicht.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050642
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  • 9
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    Electronic Resource
    Akutes Nierenversagen Pathophysiologie – klinische Beurteilung – Therapie (2000)
    Springer
    Der Anaesthesist 49 (2000), S. 349-352 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Akutes Nierenversagen ; Pathophysiologie ; Klinik ; Therapie ; Key words Acute renal failure ; Pathophysiology ; Diagnosis ; Treatment
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Acute renal failure (ARF) is characterized by an acute decrease in glomerular filtration rate (GFR). ARF complicates 4% to 23% of intensive care unit admissions, and is associated with a mortality of approximately 50% among critically ill patients. In the intensive care setting the term ARF is usually applied to acute tubular necrosis (ATN), a form of intrinsic ARF caused by ischemia or nephrotoxins. Pathophysiological mechanisms involved in the decline in GFR include tubular obstruction caused by detachment of tubular epithelial cells from the basement membrane and backleak of glomerular filtrate as a consequence of disruption of the epithelial cell layer. Vascular mechanisms involved in the pathophysiology of ATN are vasoconstriction due to an imbalance between vasoconstrictive and vasodilatatory mediators and vascular obstruction caused by cell aggregation. Currently, there is no real time method to monitor renal function comparable to the real time monitoring of blood pressure or arterial oxygen saturation. Urinary output does not reflect glomerular filtration which may be critically reduced despite normal urine volumes and creatinine clearance still provides the clinically most applicable estimate of GFR. Tubular function can be assessed using the fractional excretion of sodium or the ratio of urinary and serum osmolality; both parameters can be obtained from spot samples of urine and serum and no urinary sampling period is necessary. However, both parameters are strongly affected by the administration of loop diuretics and high fluid and sodium inputs which are common in the intensive care unit. We determined the day to day variability of creatinine clearance, fractional excretion of sodium and the urinary to serum osmolality ratio in critically ill patients without renal dysfunction (i.e. creatinine clearance in the normal range) and found differences of 16% for creatinine clearance, 79% for fractional excretion of sodium and 22% for urinary to serum osmolality ratio. Treatment of ARF is mainly supportive and there is no clinically accepted therapy that attenuates the course of ATN. Treatment of the underlying disease and renal replacement therapy are the main options for the treatment of patients with ARF. In critically ill patients continuous veno-venous hemo(dia)filtration is the first choice because it provides more hemodynamic and metabolic stability than intermittent therapy. Acute lifethreatening hyperkalemia is an indication for intermittent hemodialysis because of the higher efficacy of dialysis in the clearance of low molecular weight substances.
    Notes: Zusammenfassung In der operativen Intensivmedizin spielt die als akute Tubulusnekrose bezeichnete Form des intrarenalen akuten Nierenversagens die größte Rolle. Ursachen sind meist Ischämie und Nephrotoxizität, oft im Rahmen von Sepsis, Trauma oder großen operativen Eingriffen. Wesentliche pathophysiologische Mechanismen spielen sich am Tubulus (Obstruktion und “Back-leak”) und an den Blutgefäßen (Vasokonstriktion und Gefäßobstruktion) ab. Zur Beurteilung der Nierenfunktion auf der Intensivstation eignen sich die Kreatinin-Clearance als Schätzwert für die glomeruläre Filtrationsrate und die fraktionelle Natriumexkretion sowie das Verhältnis von Urin- zu Serumosmolalität als Parameter der Tubulusfunktion. Letztere werden durch Volumen- bzw. Natriumzufuhr und Schleifendiuretika stark beeinflusst und sind daher in der Intensivmedizin nur von begrenztem Nutzen. Die Therapie der Grundkrankheit ist die einzige kausale Behandlung des akuten Nierenversagens. Eine medikamentöse Beeinflussung des akuten Nierenversagens an sich ist bisher nicht möglich. Nierenersatzverfahren haben heute einen hohen technischen Standard erreicht. Für Intensivpatienten ist die pumpengetriebene veno-venöse Hämo(dia)filtration das Verfahren der Wahl. Zur Behandlung der lebensbedrohlichen Hyperkaliämie und bei Patienten mit Kontraindikationen für eine Antikoagulation ist die intermittierende Hämodialyse besser geeignet.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050841
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  • 10
    Electronic Resource
    Electronic Resource
    Hinweis auf eine Abnahme der Früh- und Spätmortalität beim frischen Herzinfarkt unter Nitroglycerintherapie (1983)
    Springer
    Journal of molecular medicine 61 (1983), S. 417-422 
    Details
    ISSN: 1432-1440
    Keywords: Acute myocardial infarction ; Intravenous nitroglycerin ; Infarct size ; Early mortality ; Late mortality ; Influence of the dose of nitrates
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary 60 patients with acute myocardial infarction were randomized in two groups to examine the influence of intravenous nitroglycerin on early and late prognosis. 31 patients received intravenous nitroglycerin in the first 2–3 days. One cardiac death following an emergency bypass operation occurred in the early phase during the first 14 days (3%). 5 of the 29 patients in the control group died during the same period (17%), however, cardiac cause was not entirely clear in one case. — In the late phase on the average 1 1/2 years later 3 deaths were registered in 27 treated patients (11%) compared to 7 of 23 patients in the control group (30%). For this difference in mortality reduced infarct size as well as possibly the higher dose of nitrates (38 versus 21 mg/die) were responsible. Sudden deaths and the incidence of reinfarction with and without death during the early and late observation period were significantly lower in the nitroglycerin group (11% - 3 patients) compared to the control group (39% – 11 patients,p 〈 0.01). — This pilot result seems to indicate a beneficial influence of nitroglycerin therapy in the acute phase for prognosis for the short term and long term follow up. The result should simulate trials in larger patient groups.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01488156
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